Provider Demographics
NPI:1134127947
Name:IDRISS, IMAD AR (MD)
Entity Type:Individual
Prefix:DR
First Name:IMAD
Middle Name:AR
Last Name:IDRISS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2427 S TELSHOR BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-5049
Mailing Address - Country:US
Mailing Address - Phone:575-522-1059
Mailing Address - Fax:575-522-3652
Practice Address - Street 1:2427 S TELSHOR BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5049
Practice Address - Country:US
Practice Address - Phone:575-522-1059
Practice Address - Fax:575-522-3652
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7841207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM02782Medicaid
NM02782Medicaid
NM2126943Medicare PIN